Oral health care is an essential aspect of nursing care. There are many variances in the quality and frequency of the oral care that isdelivered to patients by nursing staff, such as oral care being given a low priority when compared to other nursing care elements,oral care being neglected, and oral care delivery being dependent on the nurse’s knowledge of oral hygiene. Additionally, there aresome particular patient groups known to be at risk of oral health problems or who have existing oral diseases and conditions. Aspeople age their susceptibility increases to chronic and life-threatening diseases, and they can be at increased risk of acute infectionsincreases compromised by ageing immune systems.The aim of this literature review was to ignite the discussion related to the oralcare practices of nurses for older acute medical hospitalised patients.The review revealed that nursing staff know that good nursingincludes oral health care, but this knowledge does not always mean that oral health care is administered. Oral health care seems tobe separated from other nursing activities and is not discussed when nursing care plans are written, only when oral problems areobvious.
1. Introduction
The aim of this review of the literature is to ignite the discus-sion related to the oral care practices of nurses for older acutemedical hospitalised patients. This paper explores the litera-ture related to oral health care for older patients admitted toacute medical wards. Caring for older patients with complexmedical issues is challenging and one fundamental basic careis the provision of oral care which is often overlooked. Liter-ature relevant to this issue was reviewed to confirm our viewthat oral care was often overlooked and could be improved.
As people age, their susceptibility to chronic and life-threatening diseases as well as acute infections increases,exacerbated by compromised immune systems. Tooth lossand periodontal disease are also prevalent in the older pop-ulation [1].The number of elderly people in society is increas-ing and consequently also the number of older people in needof health care and nursing care [2]. It is projected that by 2025,
the number of elderly people will increase by 146% to 1.25billion worldwide [3]. Over the past two decades in Australia,the number of elderly people has increased by 170.6% [4].The growth in this population of older people is staggering,posing tremendous challenges in caring for this group andtheir chronic conditions.
The consequences of chronic diseases and conditions aresignificant, leading to disabilities and reduced quality of life.Individuals with the most prevalent medical problems tendto have the highest rates of oral disease, with an associationbetween poor oral health and adversemedical outcomes suchas aspiration pneumonia and cardiovascular disease [5, 6].Attention has been focused on oral care as the evidence accu-mulates to support an association between the bacteria in themouth and those respiratory pathogens that cause pneumo-nia [7].The benefits of this literature review can bring to lightpractice gaps, and areas for practice improvements for nurs-ing care of this vulnerable group, through research, quality
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improvement activities, and development of practice guide-lines within a policy framework.
2. Literature Search
A search of the literature used the search terms oral healthAND/OR oral hygiene AND nursing AND medical patientspublished between 2006 to 2012 in the databases of CINAHLand Medline. There were over 600 articles retrieved on oralhygiene/health; however there was limited literature thatspecifically focused on oral care for older medical patientsin acute care. The literature in this review was obtained fromnursing, medical, dental journals and government publica-tions, and grey literature discussing oral care, hygiene, andinpatients. The literature excluded from this review wasarticles discussing oral health for children, and oral surgery.
3. Good Oral Health
Good oral health is important. Having a clean and healthymouth contributes to a sense of well-being [8–11] allows forfluid and nutritional intake, assists with communication andquality of life [9], and assists with clear speech and communi-cation [10]. Paulsson et al. [12] note that maintenance of goodoral health is important for patients in hospital, as it con-tributes to the well-being, recovery, and nutritional needs ofthe patient, and it requires the involvement of nursing staff.
The literature suggests that oral care is not a highlytechnical skill or requires huge resources [9]. It is an individ-ualised and practiced behaviour [13] and is an essential aspectof nursing care [9, 14, 15]. As Dickinson et al. [16] state, whena person is unable to perform their own oral care in hospitalit becomes the responsibility of nursing staff. Bissett andPreshaw [8] suggest that oral care is like other personal careneeds such as bathing and toileting; it is an essential compo-nent of holistic care [14]. There are variances in the qualityand frequency of oral care delivery to patients. These vari-ances in oral care relate to different factors, such as oralcare being neglected [17–19] and oral care being given a lowpriority when compared to other nursing care elements [7, 8].Oral care is dependent on the nurse’s knowledge of oral carebest practice. Fitzpatrick [20] acknowledges that nurses’knowledge of oral hygiene is variable. Oral hygiene is oftenthought to be underrecognised by nurses for the fundamentalimpact it can have on a person’s wellbeing and health status[18]. In this context, poor knowledge has the potential to com-promise the quality of patient care [21].
The delivery of oral care to hospitalised patients is recog-nised in the nursing literature as an imperative tomaintaininghealth and wellbeing [22, 23] particularity in vulnerablegroups of patients who cannotmaintain their own oral healthwhen hospitalised. There are some particular patient groupsknown to be at risk of oral health problems or who haveexisting oral diseases and conditions. These specific patientgroups are cancer patients [24], palliative patients [13],patients who are intubated [17, 25], critically ill patients, frailpatients [12], and the elderly [9, 26].
Research evidence suggests there are subgroups of olderpeople known to be at risk of poor oral care, in particular peo-ple with dementia [27], and those that have come from resi-dential care [20, 28–30]. It is often these subgroups of olderpeople that are a majority of the patients on acute medicalwards. Acute medical wards in hospitals are frequently filledwith frail people, and this group of patients have been notedto often have comprised oral health (Andersson 1999 andOhrn et al. 2001 as cited in Paulsson et al. [12]). Fitzpatrick[20] noted that older adults due to ageing processes have aloss of soft tissue attachments, which results in loosening ofteeth root exposure, and teeth can become more brittle. Dueto the ageing process older people have oral care needs thatneed to bemet [26]. Common side effects of poor oral care arepain, difficulty with swallowing, poor or compromised nutri-tional intake [31], infection [26], systemic infection [23], andimpaired communication.
4. General Medicine: Oral Health
In the acute medical setting, nursing staff are responsiblefor assisting with oral health care. Admission to hospital isnot only a time for the active management of the presentingdisease but also an excellent opportunity for the health pro-motion and screening for undetected pathology. Preston et al.[32] discuss the importance of nurses performing daily oralcare for older people on acute, subacute, and rehabilitationwards; however these authors recognise that much of thenurses education in this important area has been providedduring their early training and regular updatesmay not occur.The lack of knowledge about oral health care among nursingstaff is also supported by Wardh et al. [33].
Nursing staff know that good nursing includes oral healthcare, but this knowledge does not always mean that oralhealth care is administered [2, 32]. In a study that was con-ducted by Wardh et al. [2] where 22 in-depth nursing inter-views were administered, it was found that the quality of oralhealth care is largely dependent upon the cooperation of theelderly patients. Some nurses reacted in a negative way due tothe risk of being bitten by elderly patients during oral healthcare. Patients who wore dentures were not always willing totake them out and cleaning dentures also seemed to be arepulsive activity. Some of the nursing staff in this study expe-rienced a lack of time as a factor inhibiting good oral healthcare. Others did not see lack of time as a problem, but instressful situations, oral health care could be easily forgotten.Ethical dilemmas can also become an issue. Some nursingstaff worry about whether it is right or wrong to force oralhealth care when an elderly patient refuses care.
5. Implications for Nursing Care
Oral health care is an important part of treatment for allpatients, particularly those who require assistance with activ-ities of daily living. The majority of hospitalised patientswithin the acute medical units are older—over age 65years [1]. Concerns regarding the nursing care older peoplereceive in the acute care environment are frequently cited in
Nursing Research and Practice 3
the literature and in particular the link between patient out-comes and nursing care. In this paper we have focused on oralcare; however other aspects of patient care require similarattention but are beyond the scope of this paper. As thepopulation ages, the likelihood of altered physical ability andpresence of disease increases, leading to a reduced abilityto perform activities of daily living, for example, oral care.Comorbid conditions most likely to be seen in the older pop-ulation include, but are not limited to, diabetes, congestiveheart failure, renal disease, glaucoma, and cataracts. Theseisues can lead to the need for hospitalisation often resulting ina protracted length of stay and the increased chance of decon-ditioning which in turn prevents older patients from attend-ing to basic care needs such as oral care. Hospitalization canrepresent the beginning of functional decline and increaseddependency that may lead to an individual requiring long-term care [34–37].The state of a patient’s oral health can havea significant impact on their health outcomes, most notablypsychosocial well-being, respiratory health, and nutritionalstatus.
Oral care is often overlooked in the context of acutemedical wards within hospitals. Routine oral care (toothbrushing, mouth toilets, etc.) are often the responsibility ofthe nurse or health assistant without the required knowledgeand skill or comprehensive hospital protocols to follow. Thisresponsibility is related to decreased functional decline lead-ing to ability to attend to ADLs. The link between functionaldecline and the need to assist with ADLs may not always beapparent to the nurses caring for hospitalised older patients.To overcome this issue the literature on this subject hasidentified the need for nurses to routinely assess oral healthstatus and to determine what assistance is required for thepatient to maintain good oral health, especially for olderpatients as debility and frailty can interfere with a patient’sability to self-manage their oral care.
Many patients are often admitted through the emergencydepartment and as such may not come in with the basics—toothbrush and toothpaste. Nursing admission assessmentsdo not routinely include assessment of the oral cavity or thepatient’s ability to manage self-care, and much of the assess-ment of oral care needs and self-care abilities of patientsis subjective with decision support protocols not routinelyavailable within the acute environment.
Anecdotal evidence suggests assessment of patient’s oralhealth on medical in-patient wards is generally poor. Patientgroups with specific needs often receive greater interventionwith their oral care. Such interventions should be applied toall hospitalised patients. It is encouraging to note that the lit-erature supports that when nurses are offered education anddecision support they respond positively and actively engage[38–40].
6. Discussion/Conclusion
The available literature supports the view that oral health careof hospitalised patients is variable and overlooked and thatnurses’ knowledge and practice are variable. Nurses play a keyrole undertaking oral health care including the identification
and evidence to guide the patients at risk for therapy-relatedoral mucositis [41], periodontal disease (a chronic inflamma-tory condition), chronic infection of the tissue surroundingthe teeth, and assessment of patients’ ability to independentlymanage their oral hygiene. Fundamental to this assessmentare both an oral assessment and a thorough functional assess-ment.This requires the involvement of the nursing staff, espe-cially in cases where oral care and any necessary dental treat-ment are vital to ensure medical treatment.
In the acute medical setting, oral health care seems to beseparated from other nursing activities and is not discussedwhen nursing care plans are written, only when oral problemsare obvious. To enhance the integration of oral care withinroutine nursing practice using a patient centred approach,some strategies may include education of staff, patient, andcarers; provision and/or increased accessibility of equipment(toothbrush, toothpaste, and mouth wash); and inclusion oforal health care as amajor component of all documentation ofnursing care [2]. Policies and practices that support themain-tenance of good oral health are needed to lessen the diseaseburden and promote healthful aging for this growing popula-tion [42]. Health care professionals need to reduce the obvi-ous service fragmentation and collaborate, especially sincethe most severe oral problems are usually found in the olderpatients [1].
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